Parents’ Perception of Febrile Seizures in Children

1 Bruno Bolvanac

1,2Nikolina Farčić

2 Ana Ljubojević

1 Karolina Kaser

2 Ivana Barać

2,3Zvjezdana Gvozdanović

1 Ivana Stojanović

1 University Hospital Centre Osijek, Osijek, Croatia

2 Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University, Osijek, Croatia

3 General Hospital Našice, Našice, Croatia

Author for correspondence:

Nikolina Farčić

University Hospital Centre Osijek, Osijek, Croatia Faculty of Dental Medicine and Health, Josip Juraj Stro- ssmayer University, Osijek, Croatia

E-mail: nikfarcic@gmail.com

https://doi.org/10.24141/2/8/1/4

Keywords: febrile seizures, perception, parents

Abstract

Aim. To examine the perception of parents of children suffering from febrile seizures in relation to manage- ment procedures for febrile seizures, parents’ gender, and their opinion regarding the need for additional education.

Methods. The cross-sectional study was conducted at the Department of Pediatrics, Osijek Clinical Hospi- tal Centre, in February and March 2023. The respond- ents were 32 parents of children hospitalized for fe- brile seizures. A questionnaire on parents’ perception of febrile seizures was used.

Results. There were 32 respondents, 15 (47%) male

and 17 (53%) female. A total of 20 (62%) respondents were not aware that their child was having a febrile seizure attack, 6 (19%) respondents thought their child was dying, and 4 (13%) respondents thought their child was losing consciousness. During seizure, a significant number of respondents, 16 (50%), of them, felt fear as the dominant emotion, and 13 (41%) re- spondents felt panic. A total of 9 (28%) respondents felt ready for recurrent febrile seizure, while 6 (19%) respondents were not or could not assess their readi- ness. A total of 29 (91%) respondents believed that they needed additional education.

Conclusion. Parents are mostly unaware that their child is having a febrile seizure and feel fear and panic. Male parents call emergency medical services significantly more often than female parents. Par- ents are not sufficiently prepared for the recurrent seizures, and most of them believe that they need additional education.

Introduction

Febrile seizures (FS) are a form of cerebral attacks which occur in young children, usually between 6 months and 5 years of age, most often due to high fever (1). Al- though febrile seizures can be frightening, they usu- ally do not cause serious medical conditions and do not leave long-term adverse effects (2). However, parents need to be educated to recognize the symptoms and signs of febrile seizures in time and seek medical help.

Etiology and epidemiology

The exact cause of febrile seizures is still unknown, although some studies indicate a possible connec- tion with environmental and genetic factors (2). Sev- eral studies identified some of the risk factors: male gender, family history of febrile seizures, high body temperature, prenatal complications, low serum calci- um level, low blood sugar level, microcytic hypochro- mic anemia, and zinc and iron deficiency (3-5).

Febrile seizures are the most common cerebral sei- zures in childhood, with an incidence of 2 to 5% in Europeans and Americans (3). A higher incidence was recorded in Japan (7-10%). The highest incidence is during the winter period as it is associated with vari- ous infectious and respiratory diseases (6).

Clinical presentation

The typical clinical picture of a febrile seizure includes loss of consciousness, disorientation, difficulty breath- ing, cyanosis, foaming at the mouth, eye rolling, fixed gaze, and generalized twitching of the arms and legs

(3). After an attack, a child may become irritable, con- fused, or sleepy, but they fully recover and come to their senses after about 30 minutes (4). Febrile sei- zures are classified as either simple, which generally do not have long-term neurodevelopmental disorders and constitute 70% of all FS, or complex febrile sei- zures (3). Simple febrile seizure is a generalized seizure without focal features, without pre-existing neurologi- cal abnormalities, lasts less than 15 minutes, and there is no recurrence within 24 hours (7, 8). Complex febrile seizures are generalized seizures with focal features, usually with pre-existing neurological abnormalities, recurrences within 24 hours, lasting longer than 15 minutes, and require anticonvulsant therapy (7, 8).

Diagnosis and treatment

When establishing a diagnosis of febrile seizures, it is most important to take a detailed medical history and perform a physical examination (8). Key items when taking medical history include description and duration of seizure, family history of seizures or pos- sible predisposition to epilepsy, recent illness, anti- biotic use, and vaccination and immunization status for Haemophilus influenzae type B and Streptococ- cus pneumoniae (9, 10). Physical examination should look for signs of meningitis such as drowsiness, ir- ritability, bulging fontanelle, occipital rigidity, and decreased muscle tone. Routine laboratory tests in children with simple febrile seizures are usually un- necessary because abnormalities in electrolytes are very rare (11). Further laboratory tests should be individualized and only prescribed after taking a detailed medical history and performing a physi- cal examination (8). Electroencephalography has no role in the acute treatment of simple febrile sei- zures, and it cannot predict recurrence. It should be performed exclusively on children who experienced complex febrile seizures, have a positive family his- tory of epilepsy or some other neurological diseases (10, 11). Any child with febrile seizures who exhibits symptoms and signs of meningitis should undergo a lumbar puncture (9).

According to the latest guidelines by Radić Nišević et al., children with simple febrile seizures should not be hospitalized at all if they are in good general condition and if the cause of fever is clear (11). The child can be discharged home after a short period of observation in a day hospital (11, 12). Seizures are mostly short- lived and stop spontaneously, not requiring prolonged treatment with antiepileptic therapy. Hospitalization is necessary if the seizure lasted longer than 15 min- utes and was a complex one, if neurological abnor- malities are present, serious infection is suspected or has unknown source, the child is under 18 months of age, and the parents or the caregivers are unable to provide quality monitoring of the child’s condition at home (11, 12). In the acute phase, treatment is aimed at determining the cause of fever and symptomatic therapy. It is important to ensure adequate hydration of the child and to reduce body temperature with rec- ommended combination of paracetamol and ibupro- fen (4, 5). During the seizure itself, the first step is to

place the child on their side and to ensure an open airway and oxygen administration. The drug of choice in most cases is diazepam administered at the dose of

0.2 to 0.3 mg/kg intravenously. An alternative method is the use of rectal enema at a dose of 0.5 mg/kg. Rec- tal absorption of diazepam is very effective, occurring within a few minutes after proper application (11, 13). Benzodiazepines such as rectal diazepam or buccal midazolam may be prescribed for use at home as ad- junctive therapy to stop seizures. They are useful for children with frequent seizures or for febrile seizures which last longer than 15 minutes and do not resolve spontaneously (11, 13).

Specifics in caring for children with febrile seizures and the importance of educating parents

The care of a child with febrile seizures is focused on identifying and treating the underlying cause of

or buccal administration of midazolam in the event of a recurrent seizure. Furthermore, teaching parents how to place the child in an appropriate position that ensures the patency of the airway and prevents the aspiration of vomited contents or accumulated saliva is crucial (16). Moreover, nurses should urge parents to contact emergency medical services in a case of recurrent seizure or take the child to the pediatric emergency room. Finally, nurses should provide emo- tional support to parents trying to alleviate anxiety, fear, and concern (11, 17).

The review of related literature found many studies on this topic. However, in the Republic of Croatia, a similar study on parents’ perception of febrile sei- zures in children has not yet been conducted. There- fore, we decided to fill this gap.

febrility and ensuring the child’s safety during and           after the seizure (13, 14). Nursing interventions in-

clude 24-hour monitoring of the child (observing the appearance and consciousness, monitoring vital functions, especially body temperature), and admin- istering antipyretics as prescribed by the pediatrician if needed. During febrile seizure episodes, the most important aspect is to ensure the child’s safety by placing them in a lateral position to maintain airway patency, then summoning a pediatrician, administer- ing oxygen therapy, and prescribed anticonvulsant therapy (11, 13-15).

Parents often lack sufficient knowledge about high fever and the potential risk of febrile seizures (16). Studies conducted in the United States showed that 77% of parents with child experiencing their first seizure think the child is dying, while 15% think the child is choking or has meningitis. Parents who have had previous encounters with febrile seizures, in an alarming 21% of cases, place the child in the correct position during the seizure (12). Nurses are an impor- tant link in educating parents as they should explain to parents that febrile seizures are usually caused by high body temperature and are not indicative of epilepsy or other neurological diseases (12). Nurses should explain to parents the possible symptoms and signs of febrile seizures so that they can recog- nize them in time and react appropriately and edu- cate them on the importance of applying antipyretic measures (11, 15). It is also important to educate parents about the rectal administration of diazepam

Aim

To examine parents’ perception of management pro- cedures during febrile seizure in their children, ex- plore parents’ perceptions in relation to gender, and investigate opinions about the need for additional education.

Methods

The cross-sectional study was conducted at the De- partments of Pediatrics, Pediatric Neurology, Genet- ics, Endocrinology, Metabolic Diseases and Rheuma- tology at Osijek Clinical Hospital Centre, in February and March 2023. The respondents were parents of children hospitalized for febrile seizures. A total of 32 respondents agreed to participate by completing the questionnaire in the given period. The question- naire was completed at the time of discharge from hospital by only one parent.

The inclusion criteria were: a signed informed con- sent to participate in the study, stay at the Depart-

ment of Pediatrics due to child’s hospitalization for febrile seizures, age 20 to 55 years, understanding and speaking Croatian language.

The exclusion criteria were: age less than 20 or greater than 55 years, unsigned informed consent to participate in the study, child’s hospitalization for other illnesses and conditions, parents of children under one month of age.

Data protection

The personal data provided is processed in accord- ance with the General Data Protection Regulation (EU Regulation 2016/679) using appropriate physi- cal, technical, and security measures. At any time, re- spondents have the right to request access, review, supplement, remove child’s private information, and the right to restrict processing, data portability, as well as the right to withdraw consent.

Ethics

The research was conducted in accordance with all applicable guidelines aimed at ensuring proper im- plementation and safety of individuals participating in the study, including the basics of good clinical practice, the Helsinki Declaration, the Health Insur- ance Act of the Republic of Croatia, and the Patients’ Right Protection Act of the Republic of Croatia. The study obtained approval from the Nursing Ethics Committee at Osijek Clinical Hospital Centre (R1- 15971-2/2022) and the Ethics Committee at the Faculty of Dental Medicine and Health Osijek (602- 01/23-12/05).

Instrument

The respondents were thoroughly explained the study in a comprehensible manner, and if they agreed to participate in the study, they received an informed consent form to sign. Once they signed the informed consent, the respondents independently completed the questionnaire. The respondents were informed that the questionnaire data and medi- cal records data would be used in the study. They were also informed about the general and specific benefits of the study, its duration and type of pro- cedures, the confidentiality of obtained data, privacy protection, voluntary participation, and the right to withdraw from participating during the study, noting that the mere refusal to participate has no impact

on the medical care provided. The instrument which was used was a questionnaire based on the Febrile Seizures: Perceptions and Knowledge of Parents of Affected and Unaffected Children questionnaire (18). With obtained author’s permission, the questionnaire was translated into the Croatian language and the section on perception was used in our questionnaire with minor adjustments. There were three sections of the questionnaire. The first section referred to the sociodemographic data of the respondents, including age, gender, level of education, and parents’ occupa- tion, as well as the child’s age, gender, and number of febrile seizures. The second section of the ques- tionnaire included objective questions on theoretical part about febrile seizures, body temperature, and parents’ actions during febrile seizure attacks. The third part of the questionnaire referred to the par- ents’ perception of febrile seizures. The perception section consisted of three parts. In the first part, the respondents had to assess their awareness during febrile seizure, determine the emotions (fear, panic, sadness) which dominated them, and assess those emotions on a scale from 0 to 10 (where 0 indicated the complete absence of the said emotion, while 10 denoted the maximum expression of the said emo- tion). Also, they were supposed to indicate who in- formed them that their child had a febrile seizure and at what body temperature value they started apply- ing antipyretic measures. In the second part, they were given yes/no statements, while the third part of the section examined the parents’ readiness for the next seizure and whether they needed additional education on febrile seizures.

Data Analysis

Categorical data were presented by absolute and relative frequencies. Numerical data were described by median and the limits of the interquartile range. Differences in categorical variables were tested with the χ2 test. All P values are two-sided. The signifi- cance level was set at α=0.05. The SPSS statistical program (version 22.0, SPSS Inc., Chicago, IL, USA) was used for statistical analysis.

Results

The study included 32 respondents, among which 15 (47%) were male and 17 (53%) were female. Most respondents, 15 (47%), belonged to the age group of 26-35 years. When it comes to the level of education, most respondents, 19 (54%) of them, completed sec- ondary education, while 10 (32%) respondents com- pleted higher education (Table 1).

In relation to child’s age, most children, 12 (38%), were in the age group of 1 to 2 years of age, while 10 (31%) children were older than 3 years. When it comes to gender, there were more male children, 21 (66%). Out of total of 32 children, 19 (59%) experienced febrile seizure once, and one child had 4-5 seizures (Table 2).

A total 20 (62%) respondents were not aware that their child was having a febrile seizure. During sei- zures, most respondents, 16 (50%), felt fear as the dominant emotion. A total of 17 (53%) respondents assessed the intensity of the emotion as 10 on the scale from 0 to 10. Most respondents, 14 (44%), of them began to reduce the body temperature when it was 38°C measured axillary (Table 3).

Among the actions taken by the parents in caring for the child during febrile seizures, the statement “I made the surrounding safe for the child” stands out, to which all 32 (100%) respondents answered affirmatively (Table 4). In relation to gender, sig- nificantly more male respondents called emergency medical services (χ2 test=5.229; p=0.02).

Out of 32 respondents, 9 (28%) felt ready for recur- rent febrile seizures. A total of 29 (91%) respondents believed that they need additional education, mostly in the form of oral and written instructions (Table 5).

Discussion

The study examined parents’ perceptions of febrile seizures in children and their opinions on the need for additional education. The results indicated in- sufficient readiness of parents for recurrent febrile seizures. Most parents also believed they were not adequately educated about the management proce- dures to follow in the case of a recurring episode. A total of 32 parents participated in the study. Most respondents were between 26 and 35 years of age. When it comes to child’s age, most children were between 1 and 2 years of age, while a few children were older than 3 years. The study by Gunawan et al. revealed that 29% of 63 children in the sample

experienced first febrile seizure between 6 and 12 months of age. The authors believe that the cause for the occurrence of febrile seizures during that pe- riod is child’s brain which has not yet reached its full maturity (19). When it comes to gender, there were more male than female children in the aforemen- tioned study. The fact that male children are more prone to febrile seizures is supported by other stud- ies. In the study by Gunawan et al., there were 63% male children in the sample of 63 children. However, in the study conducted in Saudi Arabia there were 52 (59.8%) female children in the sample of 87 children, out of which 37% had more than one episode of fe- brile seizure (20). The findings of that study contra- dict those of this one and other studies.

Most parents were not aware that their child was hav- ing a febrile seizure. Six respondents believed that their child was in a life-threatening situation, four of them thought their child was losing consciousness, three believed their child’s temperature was rising or that they were choking. Additionally, one respond- ent each considered it an allergic reaction, an epi- leptic seizure, or cessation of breathing. Half of the respondents felt fear as the dominant emotion, thir- teen respondents felt panic, and three respondents felt sadness. Over half of the respondents assessed their emotions as highly expressive. In the study by Kanemura et al. in 2013, a total of 41% of parents stated that they were afraid because they thought their child would die during the seizure, while 29% of them believed that the child had serious difficulties

(21). During a febrile seizure, the paralyzing fear ex-

perienced by most parents often hinders them from acting appropriately and administering timely first aid to the child. In this study, most respondents indi- cated that their child’s febrile seizure was communi- cated to them by a physician. A significant proportion of respondents (44%) began reducing their child’s body temperature only when it reached 38 ºC or higher when measured axillary. In children who have already had febrile seizures, reducing body tempera- ture should be initiated at axillary temperature of

37.5 ˚C, i.e., rectal or auricular temperature of 38 ˚C. The second part of the questionnaire consisted of yes/no question about actions taken during febrile seizure. The statement “I made the surrounding safe for the child” stands out for being answered affirma- tively by all respondents. The statement “I placed the child on a soft and safe surface”, was answered affirmatively by most respondents. Only eleven re-

spondents answered affirmatively to the statement “I tried to restrain a child in spasm”, which is a dev- astating finding. In the study conducted in 2020 by Sayed, all parents placed their child on a soft and safe surface. Most respondents (86.7%) noticed the symptoms and followed the duration of the seizure, and 93.3% of them did not try to restrain the child during the seizure (22). During a seizure, the child should be restrained, i.e., involuntary movements of the extremities should be prevented to avoid self- harm and mitigate the risk of injury to others in the immediate surrounding. Most respondents answered affirmatively to the statement “I called emergency medical services”. Significantly more male respond- ents called emergency medical services. In conversa- tion with parents during this study, it was found that mostly mothers were first to help the child, while fathers were the ones who called emergency medi- cal services. In several studies, 100% of the respond- ents called for emergency medical services (22, 23). The statement “I put a hard object in child’s mouth” is also noteworthy as it was answered negatively by all but two respondents. The results of the study con- ducted in Nigeria and Turkey indicate that 61.2% of parents would put a hand or a spoon in their child’s mouth to prevent choking, while 39.3% of parents would put any hard object in their child’s mouth (24, 25). The results of this study showed that only two respondents tried to put a hard object in the child’s mouth during a seizure. The results of the study by Kanemura et al. showed that 3% of parents patted or hit the child’s back or tried to remove a foreign body from the throat during a seizure because they suspected that the child was choking on something. As many as 9% of them tried to separate the child’s clenched teeth, while 7.7% of the parents shook the child violently. Only 4% of parents completely undressed the child, and none attempted mouth- to-mouth resuscitation (21). According to the study by Elbilgahy in Egypt, mostly mothers (71%) gave mouth-to-mouth resuscitation, while in the study by Kayserili in Turkey, only 10.7% of mothers gave mouth-to-mouth resuscitation (26).

First aid for seizures includes providing a safe sur- rounding to avoid injury, calling emergency medical services, placing the child on the left or right side with the head facing the floor, removing excess clothing, especially around the neck, placing a soft pillow un- der the head, avoiding putting any objects in the oral cavity, applying anticonvulsant therapy, and monitor-

ing the duration of seizure. This study identified key moments in which parents did not respond effectively during a seizure. One was putting a hard object in the oral cavity during an attack, and the other, extremely important one, was not preventing self-harm of the child by restraining the body in a spasm.

The third part of the questionnaire examined parents’ opinion on their readiness for a recurrent seizure and their need for additional information and education about febrile seizures. Among 32 respondents, nine felt ready for a recurrent seizure, eleven felt partially ready, and six respondents were not ready or could not assess their readiness. In a study by Westin et al. conducted in 2018, most parents of children with recurrent seizures reported that the experience from the first seizure, along with the information received from healthcare professionals, significantly enhanced their readiness and confidence in dealing with sub- sequent seizures (27). The results of this study in- dicated that most respondents felt much more con- fident after receiving information from healthcare professionals. Almost all respondents believed that they need additional education about febrile seizure, mostly in the form of oral and written instructions. Given that febrile seizures are very stressful events, it would be helpful if detailed information about them became part of anticipatory guidance provided by pediatricians and pediatric nurses to all new pa- tients. Children with febrile seizures require a holistic approach and their nurses should possess special- ized skills and knowledge required for their roles. Educating parents on home care for their child in the case of recurrent seizure is among the crucial respon- sibilities of nurses. Before the child’s discharge from hospital, parents should receive information through both oral communication and informative written ma- terials such as leaflets and brochures. These written materials will serve as a helpful reference, allowing them to review details provided verbally during the hospitalization once they had the opportunity to calm down and the initial shock subsided (28). Addi- tionally, online instructional videos and educational resources about febrile seizures can be made avail- able to enhance understanding. It is very important to offer parents the opportunity to compile a list of important contact numbers of professionals who can assist them at any moment. Healthcare professionals at the Department of Neuropediatric should continu- ously improve their knowledge and skills to deliver the utmost care to young patients and their parents.

The limitations of this study are that it was conduct- ed in one institution, on a small number of respond- ents and in a short period. A worrisome fact is that so many children were hospitalized for febrile seizures in such a short period.

Conclusion

The results of the study show that parents are not sufficiently prepared for recurrent seizures. Also, most parents believe that they need additional edu- cation about recurrent seizures. There is no signifi- cant difference in parents’ perception of febrile sei- zures in children in relation to their gender, except for the question of calling emergency medical ser- vices because significantly more male parents called emergency medical services. Most parents were in fear and not aware that their child was having a fe- brile seizure. All parents acted correctly by providing a safe surrounding for their child during seizure. This study can provide a basis for further research on the topic.

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PERCEPCIJA RODITELJA O FEBRILNIM KONVULZIJAMA U DJECE

Sažetak

Cilj. Ispitati percepciju roditelja djece oboljele od fe- brilnih konvulzija (FK) o postupcima tijekom napadaja FK-a, percepciju roditelja u odnosu na spol te mišlje- nje o potrebnoj dodatnoj edukaciji.

Metode. Presječno istraživanje provedeno je u Kli- ničkom bolničkom centru Osijek na Klinici za pedija- triju tijekom veljače i ožujka 2023. Ispitanici su bili 32 roditelja djece hospitalizirane zbog febrilnih kon- vulzija. Primijenjen je upitnik o percepciji roditelja o febrilnim konvulzijama.

Rezultati. Ispitano je 32 roditelja, od kojih su 15 (47 %) muškarci i 17 (53 %) žene. Ukupno 20 (62 %) roditelja nije bilo svjesno da im dijete ima napadaj FK-a te ih je šest (19 %) mislilo da im dijete umire, a četvero (13 %) ispitanika mislilo je da im dijete gubi svijest. Za vrijeme konvulzija čak 16 (50 %) ispita- nika osjećalo je strah kao dominantnu emociju, a 13 (41 %) ispitanika osjećalo je paniku. Definitivno spre- mnima za ponovne napadaje FK-a osjeća se devet (28 %) roditelja, dok po šest (19 %) ispitanika navodi da definitivno nisu spremni ili da ne mogu procijeniti jesu li spremni. Ukupno 29 (91 %) ispitanika smatra da su im potrebne dodatne edukacije.

Zaključak. Roditelji većinom nisu svjesni da dijete ima napadaj FK-a te osjećaju strah i paniku, muškarci su znatno više puta pozvali hitnu medicinsku pomoć od žena. Roditelji nisu dovoljno spremni za idući napadaj te većina smatra da su im potrebne dodatne edukacije.

Ključne riječi: febrilne konvulzije, percepcija, roditelji